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World Psychiatry. 2007 June; 6(2): 68–74. | PMCID: PMC2219905 |
The vision of recovery today: what it is and what it means
for services MARIANNE FARKAS1 1Center for Psychiatric Rehabilitation, Sargent College of Rehabilitation Sciences, Boston University, 940 Commonwealth Ave. West, Boston, MA 02214, USA In the past, practice in mental health was guided by the belief that individuals
with serious mental illnesses do not recover. The course of their illness
was either seen pessimistically, as deteriorative, or optimistically, as a
maintenance course. Research over the past thirty to forty years has indicted
that belief and shown that a vision of recovery can be achieved for many individuals.
People with serious mental illnesses have themselves published accounts of
their own recovery as well as advocated for the development of recovery promoting
services. In North America and other regions, policies have been developed
to make recovery the guiding vision of services. Today, particularly in the
United States, much effort is going into the transformation of services and
systems to achieve recovery outcomes. Despite these trends, the idea of recovery
remains controversial and, some say, even illusory. This article clarifies
the meaning of the term "recovery", reviews the research and first person
accounts providing a rationale for recovery, and sets out implications for
developing recovery oriented services. Keywords: Recovery, recovery research, recovery oriented services, serious mental illnesses For many years, the conventional wisdom in the field of mental health has
been that severe mental illnesses, particularly schizophrenia, inevitably
result in progressive deterioration. Professional practice has then understandably
focused on managing psychopathology and its symptoms. Research efforts in
the 1960s, 1970s and 1980s documented the heterogeneity of outcomes, particularly
for individuals with schizophrenia ( 1- 3), including often regaining functioning
over the long term, developing friendships and reporting satisfying lives
( 4- 7).
The practice field, however, continued to be organized to fend off relapse
and deterioration ( 8, 9). It is unfortunate but not surprising that it has taken the practice field
so long to adopt this forty year old understanding of the possibility of recovery.
The large gap between research findings and adoption in practice has been
often cited as a major barrier to innovation in mental health ( 10- 13). In fact, recent
analyses of the state of mental health systems in the United States have concluded
that mental health care in America fails a wide variety of individuals, but
particularly fails those with serious mental illnesses ( 14), because it is "not oriented to the single most important
goal of the people it serves, that of recovery" ( 15).
Furthermore, the U.S. President's New Freedom Commission report strongly urged
the adoption of the notion of recovery as possible for all and as the guiding
vision for the system. Bringing the vision of recovery into the practice field
requires an understanding of what is meant by recovery, the research findings
that provide a rationale for recovery and the implications of these findings
for the delivery of services ( 15). Even though there is no explicit consensus about the meaning of the term,
the notion of recovery is guiding policies and practices in many American
state mental health systems as well as those of other countries, such as Canada
and New Zealand ( 16- 21). Consumer researchers have examined how systems can facilitate
or hinder recovery and identified systems performance indicators ( 22). Recovery is also listed as a performance indicator to
monitor and improve the outcome of individuals served by American state mental
health systems ( 23). Recovery has been the subject of debate among advocates, providers, family
members and other stakeholder groups over the past few decades. Some who view
mental illnesses as primarily biological in etiology have questioned whether
recovery is even possible and have argued that using the term will give false
hope both to those diagnosed and those who care about them ( 24). On the other side of the debate, former patients and
other critics of biological approaches have questioned whether mental illnesses
even exist as medical entities and prefer to think of life crises as normal
parts of human existence ( 25). From
this viewpoint, there can be no "recovery" because there has been no illness.
In addition to such controversy, most stakeholders agree that the term itself
can be confusing and seem illusory. For example, words such as "recovery",
"rehabilitation", and "reintegration" have often been confused one for the
other ( 26). "Rehabilitation" is a field
or a service designed to facilitate success and satisfaction in a specific
valued role chosen by the individual ( 27).
"Reintegration" into society is an outcome which can be achieved using mental
health treatment services, such as community psychiatry and rehabilitation
among others, as well as political action and community organizing to promote
solidarity and openness to individuals with serious mental illnesses. "Recovery",
on the other hand, is neither a service nor a unitary outcome of services.
Researchers, providers and, most importantly, individuals with serious mental
illnesses themselves have contributed to the meaning of the term as it has
evolved over the past few decades. Some clinical research groups have identified recovery as the alleviation
of symptoms and a return to premorbid functioning ( 28).
Working definitions by several groups ( 6, 29) have operationalized variables such as
symptom remission, vocational functioning, independent living, and peer relationships.
Consumer and psychiatric rehabilitation literature, however, does not hold
the view that either symptom remission or a return to premorbid functioning
is necessary for recovery to occur ( 8, 30). Individuals with mental illnesses have long written about their experiences
of recovery ( 31- 33). Approximately fifty years ago, the ex-patient movement
identified the language of recovery to help to make sense of their own experiences
and to develop an alternative vision of mental illnesses ( 34). The ideas of the Independent Living Movement (i.e.,
centers established and managed by people with physical disabilities) ( 35) heavily influenced mental health consumers'
views that recovery remains possible, even if a person's functional limitations
may not change. In the area of physical disabilities, consumers and rehabilitation
specialists have long known that it is possible to regain employment, go back
to school, or regain a valued position in society despite never having regained
the use of one's limbs or senses ( 8, 36, 37).
As Anthony and colleagues ( 8, 38) point out, the experience of recovery from mental illnesses
includes not only regaining a valued role, but also recovering from the effects
of having been diagnosed with a mental illness (e.g., discrimination, disempowerment,
negative side effects of unemployment, crushed dreams) as much as from the
effects of the illness itself. Like trauma survivors, individuals with serious
mental illnesses may experience these effects as having changed their lives
irrevocably ( 39) and thus feel simply
unable to return to their lives prior to the onset of illness, but endeavor
rather to incorporate the illness experience into a new identity. Deegan ( 30) eloquently makes this point when she
says: "The goal of the recovery process is not to become normal. The goal
is to embrace our human vocation of becoming more deeply, more fully human".
First-person accounts and consumer advocate descriptions of recovery then
underscore the fact that recovery was the personal journey of an individual
in taking back control of his or her life, or the lifelong process of "becoming
more fully human", even with functional limitations and deep traumas. The Center for Psychiatric Rehabilitation at Boston University has developed
a working definition of recovery, derived from an analysis of first-person
narratives and the views expressed by members of the consumer/psychiatric
survivor movement. Recovery from mental illnesses has therefore been defined
as "the deeply personal process of changing one's attitudes, feelings, perceptions,
beliefs, roles, and goals in life /italic--". It was further conceptualized
as "the development of new meaning and purpose in one's life, beyond the impact
of mental illness" (8,38,40). This definition
includes and/or implies some of the most common elements of many other definitions
that have emerged over the past fifteen years: the importance of renewing
hope and meaning (7,18,30,41,42); overcoming
stigma and other sources of trauma associated with serious mental illnesses
(7,30,43) and assuming control over one's life
(28, 41,44-47).
Empowerment which closely accompanies the element of assuming control over
one's life and, by extension, the notion of regaining citizenship are additional
elements which are, perhaps, more implied than stated in Anthony and colleagues'
definition, but have certainly been identified as a critical factor by the
Center for Psychiatric Rehabilitation and others (7,8,41,47,48).As pointed out by Rogers et al ( 49),
it is somewhat difficult to classify the research that has a direct bearing
on recovery, given the historical lack of clarity about the term. Traditionally,
this research includes longitudinal studies of individuals with schizophrenia,
qualitative studies, and firstperson accounts of individuals with major mental
illnesses. In addition to these traditional sources, developments in other
fields of study, such as positive psychology and behavioral science research,
have also begun to be seen as contributors to knowledge about recovery. Recovery research is somewhat unusual in the field of mental health in
that it has placed a high value on researchers who are themselves exemplars
of recovery (i.e., researchers who are also ex-patients). This focus has contributed
to broadening the kinds of questions under study. For example, it was consumers
themselves who first recommended the investigation of issues related to success
by individuals who had achieved meaningful lives rather than focusing only
on issues related to relapse and deterioration, a shift in focus which contributed
to the momentum of the recovery vision ( 8). Longitudinal studies Studies designed to examine the long-term outcome of individuals with schizophrenia
have been recently summarized by Harding ( 50).
These include studies from Switzerland ( 51, 52), Germany ( 53),
Japan ( 54) and the United States ( 1, 2, 55). Moreover, the World Health Organization
recently conducted a multinational study in which outcomes among diverse cultural
groups were examined ( 56). The follow-up
period in all of these studies ranged from 22 to 37 years, with sample sizes
ranging from 186 to 269 individuals, mainly those hospitalized with a diagnosis
of schizophrenia. In the aggregate, one half to two thirds of the subjects
were reported as recovered or significantly improved. The outcome indicators
for recovery in these studies included: no further symptoms, no use of psychotropic
drugs, living independently in the community, working, and relating well to
others with no behaviors displayed that others considered unusual. The designation
of "significantly improved" was given when all recovery outcome indicators
but one were present ( 50). These findings
have largely held up over time. Despite variations across studies, it is clear
that, when viewed through the lens of several decades, significant improvement
has been reported for a substantial number of individuals with major mental
illnesses. Qualitative studies The richness of the experience of recovery has been captured in several
qualitative studies and analyses of first-person accounts. They have shown
that individuals with serious mental illnesses have achieved recovery both
using mental health services and without professional intervention. While
it is clear that some do achieve a meaningful life ( 57, 58) without professional
intervention, we currently do not have sufficient data to explain or understand
which individuals recover on their own or how this occurs. Several authors ( 59- 62) conducted qualitative studies to describe elements in
the course of the recovery journey. In their in-depth interviews of small
numbers of individuals over time, they were able to describe common challenges
in the recovery process, including elements such as coping with a sense of
loss, a loss of power and valued roles (such as parent, worker), a loss of
hope, struggles to prevent relapse and to redefine oneself and one's social
identity. In addition, they identified processes that appeared to be important
to the experiences described, such as discovering a more active sense of self,
for example, taking stock of strengths and weaknesses and fostering empowerment. A number of researchers recently conducted meta-analyses of first-person
accounts and narratives of the process of recovery ( 7, 50, 63, 64), which have
provided information on the explanatory frameworks used by individuals to
understand the cause of their mental illnesses. For example, some individuals
view their condition as the result of a spiritual crisis, others see it as
biological, others as environmental or political, while others view it as
the result of specific trauma. Researchers have also examined the processes, coping factors and tasks
identified as important to accomplish for recovery to occur ( 63, 65). Examples of
categories of the recovery process include those identified by Jacobson ( 63): recognizing the problem, transforming
the self, reconciling the system, reaching out to others. Recovery experiences
have also been categorized as being overwhelmed by the disability, struggling
with the disability, living with the disability and living beyond the disability
( 58). Coping factors suggested by Ralph
( 64) include personal factors (e.g.,
insight), external factors (social supports), self-managed care (e.g., participating
in one's own health care) and empowerment (e.g., sense of self efficacy).
Tasks or themes to accomplish recovery suggested by Ridgway ( 7) include reawakening of hope, achieving understanding of
disability, engagement in life, active coping, reclaiming a positive sense
of self and regaining a sense of meaning and purpose. The power of a person
who believes in the individual, even when the individual cannot believe in
him or herself, has been cited, almost universally, as critical to recovery
( 8, 31, 50). Contributions of positive psychology and behavioral science The fields of positive psychology and behavioral science have begun to
contribute to our emerging understanding of the factors associated with recovery.
Positive psychology argues that psychology and psychiatry, in general, have
focused, to their detriment, almost exclusively on the identification and
alleviation of disorder ( 66). Positive
psychology, while focused on individuals without disabilities, emphasizes
growth, personal accomplishments and success in valued roles ( 67), which are also identified as recovery outcomes. Rogers
et al ( 49) argue that the dimensions
and processes proposed by positive psychology are equally important for individuals
with serious mental illnesses. In addition, behavioral and social science
research conducted with the general population in the areas of self-esteem,
selfregulation, self-judgment and subjective well-being is all pertinent to
the process and outcome indicators of recovery. For example, Diener's work
( 68) on the individual, cultural, and
situational effects on subjective well-being furthers our understanding of
individual processes for recovery. Moreover, this research is useful to the
investigation of other questions, such as whether or not, as people progress
toward recovery, their motivation shifts from preventing losses to promoting
gains ( 69), or how to understand the
perceived risks of pursuing self-esteem goals ( 70). In summary, recovery research has shown that recovery: is possible over
time; represents a multidimensional, highly individualized non-linear process
that can be described; may be achieved with or without professional intervention;
has multiple objective and subjective outcome indicators that reach beyond
symptom reduction. IMPLICATIONS FOR SERVICES Recovery has been suggested as the critical overarching goal or mission
that can serve to integrate the efforts of all services in mental health,
including self-help services, basic support, rights protection as well as
treatment and rehabilitation services ( 71). While recovery is not an intervention that providers can make, all services
can contribute (or not) to the outcomes and experience of recovery (e.g.,
well-being, self-esteem, valued roles, symptom reduction, empowerment, etc.).
Intervention research has suggested that, while the picture is not totally
clear cut, we are currently able to facilitate or promote some indicators
of recovery outcomes. Psychiatric rehabilitation has been described as a public health strategy
in which all stakeholders, including consumers, families, policy makers, researchers
and clinicians play an important role ( 72),
including community psychiatrists ( 73).
Rehabilitation has been identified as effective in helping individuals to
gain or regain valued roles in domains such as residential/community, vocational
or employment and educational or schooling ( 74- 78), outcomes recently reconfirmed as beyond
those achieved by medication alone ( 79).
Farkas ( 27) notes that these outcomes
can promote recovery by increasing an individual's social capital, resources,
empowerment and full citizenship in society. In the field of treatment, effective interventions that promote at least
one of the recovery outcomes include, among others, cognitive behavior interventions
( 80), medication management ( 81, 82),
integrated mental health and substance abuse treatment, and family psychoeducation
( 83). Qualitative studies ( 58) have also reported that support from others, effective
medication and symptom management strategies, access to medical and psychiatric
services, and basic resources like shelter, are recognized by consumers themselves
as making a difference in an individual's recovery. Based on the present state of our knowledge about what constitutes recovery,
its process and its outcomes, it is possible to identify some key ingredients
of a recovery oriented program, regardless of which specific practice is used.
When evidence-based practices are developed, described and replicated ( 84), possible important philosophical elements
of a practice may be omitted, because they may not as yet be empirically linked
to the traditional outcomes reported. Yet these features may be important,
because they can significantly alter the consumer's personal experience of
the program and thus his/her unique process of recovery ( 85, 86). Similar recognition
has emerged in general medicine of the importance of value based practice
in providing not only effective evidence based interventions, but also those
interventions which are perceived to be meaningful to the patient ( 87). While there are many values that may be associated with recovery-oriented
services, there are at least four key values that support the recovery process
and that appear to be commonly reflected in the consumer and recovery literature.
These values are: person orientation, person involvement, self-determination/choice
and growth potential ( 88). Farkas et
al ( 89) have detailed an initial comprehensive
set of recovery standards for program missions, policies, procedures, documentation
and staffing, based on these core recovery oriented values. Regardless of
the type of services delivered within the programs (i.e., treatment, case
management, rehabilitation, crisis intervention, etc.), these values can guide
recovery promoting service delivery. Person orientation First-person narratives convey that people with psychiatric disabilities
appreciate when mental health professionals express interest in them as a
person and in roles other than as "patient" ( 90, 91). They may feel damaged by professionals
who refuse to connect in a more holistic way ( 92).
Consequently, recovery oriented services encourage the assessment and development
of talents and strengths rather than narrowly focusing on deficits. "Person
orientation" also guides services to promote access to resources and environments
outside the mental health system where meaningful, socially valued roles can
be attained, rather than limiting individuals to ghettos created by mental
health service programs. Person involvement Research data suggest that outcomes are better for people who have an opportunity
for meaningful involvement in the planning and delivery of their services
( 93). Consumer involvement in designing
and delivering mental health services (e.g., program planning, implementation
and evaluation) is seen as a critical component of a quality management system
for any mental health service ( 94),
as well as critical to the development of a sense of empowerment ( 95) and a shift in self-identity. Actively promoting the
hiring of individuals with serious mental illnesses as peer providers and
support personnel, as well as in the role of helping professionals and administrators,
is becoming an important element in the development of a recovery oriented
service or system ( 8, 22, 48). The consumer
movement's slogan "Nothing about us without us" sums up its expectations of
partnership and involvement in a recovery oriented service. Self-determination/choice Self-determination and self-choice is the cornerstone of a recovery process.
The opportunity to choose one's longterm goals, the methods to be used to
get to those goals and the individuals or providers who will assist in the
process, are all components of a service acknowledging this value. Several
mental health program models, such as psychiatric rehabilitation ( 78, 96), supported
housing ( 97), psychosocial clubhouses
( 98) and some case management programs
( 99), articulate the values of choice
and partnership. Davidson and Strauss ( 100) note,
based on their qualitative research, that coercion has the effect of diminishing,
rather than strengthening the self. Compliance does not promote the development
of meaning and purpose in life and hence is a barrier to recovery. Placing
a person in facility, job, school program or prescribing medications without
exploring the person's preferences may achieve the outcome of reducing symptoms
or gaining a role in society, without promoting the individual's sense of
self, empowerment, well being or recovery. Helping an individual take back
a meaningful life requires supporting self-determination and, if necessary,
actively creating opportunities and providing assistance to develop more experience
in making informed choices. If a person cannot choose a specific type of role
because he/she has not, for example, worked in many decades, a recovery oriented
service would organize a variety of work experiences to help the individual
figure out what his/her preferences might be. A recovery oriented service
based on choice also provides individuals with sufficient education about
medications, their intended outcomes and side effects to permit the individual
to make choices from a menu of possibilities about which medications, if any,
he/she wishes to use to support his/her recovery process. Hope Hope for the future is an essential ingredient in all recovery oriented
services. A commitment to creating and maintaining hopefulness in both service
participants and their practitioners is critical to selecting, training and
supervising staff as well as developing program activities in recovery oriented
services. While research shows that professionals do no better than random
chance in predicting success ( 8), some
staff may believe it is unrealistic to expect their patients to recover because
they are "too sick" or "too disabled". Because such staff lack hope themselves,
they cannot promote a recovery orientation. Services that promote activities
focused on simple maintenance or the prevention of relapse, without opportunities
and support to move beyond maintenance, are not recovery oriented. For example,
services need to be able to support the aspirations of those who wish to go
to or return to university or community colleges, as well as those who wish
to complete grade school or high school. Services need to be able to facilitate
the goals of those who wish to get married, have families, and start their
own businesses, as well as those who wish to live in some type of supported
residence and work in a more sheltered employment situation. Hopefulness does not mean using the promise of recovery as a new tool to
label or devalue the individual. The impulse to label someone as "unmotivated"
should not now be replaced by the label of "recovery failure" because recovery
goals are not met in the moment. Hope means remembering, as research has shown,
that recovery can be a long-term process with many setbacks and plateaus along
the way. While the field is still developing its understanding of the process and
meaning of recovery, it is clear that recovery is a reality that is possible
to promote. Services should use practices with some evidence base that are
reflective of, at a minimum, the four core recovery values (person orientation,
person involvement, self-determination/choice and growth potential) in order
to remain relevant as well as effective in the lives of the people they serve.
Services focusing on people or the full human experience, not "cases", partnership
not compliance, choice not coercion, and a commitment to hopefulness, not
helplessness hold the promise of more than just survival or maintenance. Such
services promote recovery or the realization of a meaningful life for individuals
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